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APPLICATION FORM APPLICATION FOR THE POST OF COMPUTER SHIKSHA MITRA & TRAINING

District for Apply………………………………….

1. FULL NAME (IN BLOCK LETTERS) (leave one space blank between two parts of your name.)

2. ADDRESS FOR CORRESPONDENCE: P I N 3. Indicate Category to which you belong to by marking “X” in the appropriate

box. SC ST OBC GEN

(Please Attach Attested Copy of Certificates wherever necessary) 4. Date of Birth (As per School leaving Certificate SSC/SSLC) Date Month Year Age (as on 01.07.2010): _________ Years ____________ months. 5. Details of Application fees:

Name and address of the issuing Bank Date of issue DD No. Amount (Rs.)

(Bank demand drafts may be drawn on any scheduled Bank in favour of “CENTRAL COUNCIL OF RURAL DEVELOPMENT” payable at Lucknow. They are to be crossed “A/c Payee Only”) (Fee for the post is Rs.200/- for General candidates including OBC and Persons With Disabilities and Rs.100/- for SC/ST candidates) Payment by Cash, Cheque, Postal Stamps, Money Order etc. will not be accepted and such applications will be rejected) (Any communication through e-mail will not be accepted.) 6. YOUR CONTACT NO. TELEPHONE NO. (with STD code) _________ 7. (i) GENDER : Mark “X” in the appropriate Box

Affix your latest passport size photograph and sign across the same

MALE FEMALE

(ii) Whether you belong to Minority Community? Yes No (Mark “X” in appropriate box)

If yes, please state the religion.

(iii) In case of SC/ST/OBC Candidate: Name of the Caste/Tribe/Class: _______________

8. FATHERS/HUSBAND’S NAME (IN BLOCK LETTERS) 9. NATIONALITY : ___________________ 10. PLACE OF BIRTH: Place: _____________ Dist:____________ State: ________ 11. PERMANENT ADDRESS (IN BLOCK LETTERS): P I N 12. Educational and Professional Qualifications: Details of Education (10th standard onwards) Examination Passed

Name of the Board/

University

Subjects Group

Year of passing

Percentage of aggregate marks

Class/ Division.

10th

10+2th

Graduation

(If space is not sufficient please attach separate sheet) 13. Languages known * (Mark “X” in the appropriate box) Sl. No. Language Read* Write* Speak* 1. English 2. Hindi 14. Experience. ___________________ DECLARATION:

I hereby declare that all statements made in this application are true, complete and correct to

the best of my knowledge and belief. I understand that in the event of any information being found false or incorrect any stage or not satisfying the eligibility criteria according to the requirements of the relative advertisement, my candidature/appointment is liable to be cancelled/terminated.

Place: Date : SIGNATURE OF CANDIDATE.